From the Guidelines
For an 83-year-old hospitalized patient with impaired sleep, non-pharmacological approaches should be tried first before considering medications, prioritizing cognitive behavioral therapy for insomnia (CBT-I) and sleep hygiene practices. These approaches include maintaining a consistent sleep schedule, reducing noise and light in the room, avoiding caffeine and fluids before bedtime, and ensuring comfort with proper positioning and pain management.
Key Considerations
- The goal is to improve sleep quality and reduce distress or dysfunction caused by the disorder, focusing on morbidity, mortality, and quality of life outcomes.
- If medication is necessary, low-dose melatonin (0.5-2 mg) taken 1-2 hours before bedtime is often the safest initial choice for elderly patients 1.
- For short-term use, trazodone 25-50 mg at bedtime may be considered if melatonin is ineffective, as suggested by guidelines for managing insomnia in adults 1.
- Traditional sleep medications like benzodiazepines and "Z-drugs" (zolpidem, eszopiclone) should generally be avoided in elderly hospitalized patients due to increased risks of confusion, falls, and respiratory depression, as highlighted by the risks associated with their use in demented elderly patients 1.
Environmental and Behavioral Interventions
- Addressing environmental factors that disrupt sleep in the hospital setting, such as frequent vital sign checks, medication administration, and unfamiliar surroundings, is crucial.
- Ensuring a quiet, dark environment and minimizing disruptions can help improve sleep quality.
- Educating patients and caregivers about sleep hygiene practices and the importance of maintaining a regular sleep schedule can also be beneficial.
Medication Use
- Any sleep medication should be used at the lowest effective dose for the shortest duration possible, with regular reassessment of its necessity and effectiveness.
- The choice of medication should be based on the patient's response to the first-line treatment and consideration of potential side effects and interactions with other medications.
From the FDA Drug Label
In patients with depression, a possibility for suicide should be borne in mind; benzodiazepines should not be used in such patients without adequate anti-depressant therapy. Lorazepam should be used with caution in patients with compromised respiratory function (e. g. COPD, sleep apnea syndrome). Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam.
The usual precautions for treating patients with impaired renal or hepatic function should be observed As with all benzodiazepines, the use of lorazepam may worsen hepatic encephalopathy; therefore, lorazepam should be used with caution in patients with severe hepatic insufficiency and/or encephalopathy.
Clinical studies of lorazepam generally were not adequate to determine whether subjects aged 65 and over respond differently than younger subjects; however, the incidence of sedation and unsteadiness was observed to increase with age
For an 83-year-old hospitalized patient with impaired sleep, melatonin may be a better option than lorazepam due to its safer profile in the elderly.
- Melatonin is a nighttime sleep aid for occasional sleeplessness and is 100% drug-free and non-habit forming 2.
- Lorazepam should be used with caution in elderly or debilitated patients, as they may be more susceptible to its sedative effects, and the incidence of sedation and unsteadiness increases with age 3 3. It is recommended to use the lowest effective dose and monitor the patient frequently.
From the Research
Sleep Aids for Hospitalized Elderly Patients
To address the sleep needs of an 83-year-old hospitalized patient, several factors must be considered, including the patient's overall health, potential sleep disorders, and the hospital environment.
- Non-pharmacological interventions are recommended as the first line of treatment for sleep disturbances in hospitalized patients, as they can be effective and have fewer side effects than pharmacological treatments 4, 5, 6, 7, 8.
- Examples of non-pharmacological interventions include:
- Timed lights-off periods
- Minimizing night-time noise
- Distribution of earplugs at bedtime
- Cued toileting before bedtime
- Identification and reduction of modifiable interruptions 6
- Cognitive behavioral therapy (CBT) has been shown to have a mild effect on sleep problems in older adults, particularly for sleep maintenance insomnia 7.
- Bright light therapy and physical exercise may also be beneficial for improving sleep quality in older adults, although more research is needed to confirm their effectiveness 7.
- Pharmacological therapies, such as hypnotics and sedatives, should be used judiciously and only when necessary, as they can have significant side effects and interact with other medications 8.
- A comprehensive assessment of the patient's sleep complaint, including a review of factors that could exacerbate sleep disturbances, is essential for developing an effective treatment plan 8.